100-22 Medicare Quality Reporting Incentive programs Manual: Chapter 1-The Physician Quality Reporting Initiative (PQRI)

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Medicare Quality Reporting Incentive Programs
Manual
Chapter 1 – The Physician Quality Reporting System
Table of Contents
(Rev. 82, 03-22-19)
Transmittals for Chapter 1
10 – Background
20 – Eligible Professionals
20.1 – Eligible Professionals Not Able to Participate
20.2 – Professionals Not Eligible to Participate in the Physician Quality Reporting
System and Not Qualified to Earn an Incentive Payment
20.3 – Participation by Group Practices
30 – Payment for Reporting
40 – Reporting Period
50 – Form and Manner of Reporting
50.1 – Claims-based Reporting Mechanism
50.1.1 – Coding and Reporting Principles for Claims-based Reporting
50.2 – Registry-based Reporting Mechanism
50.3 – Electronic Health Record-based (EHR-based) Reporting Mechanism
60 – Physician Quality Reporting System Measures
60.1 – Reporting of Individual Physician Quality Reporting System Quality Measures
60.2 – Reporting of Physician Quality Reporting System Measures Groups
70 – Criteria for Determination of Satisfactory Reporting
70.1 - Criteria for Determination of Satisfactory Reporting of Individual Measures and
Measures Groups for Individual Eligible Professionals
70.1.1 – Criteria for Determination of Satisfactory Reporting of Individual
Measures for Claims-based Reporting
70.1.2 – Criteria for Determination of Satisfactory Reporting of Individual
Measures for Registry-based Reporting
70.1.3 – Criteria for Determination of Satisfactory Reporting of Individual
Measures for EHR-based Reporting
70.2 - Criteria for Determination of Satisfactory Reporting for Group Practices and
Process for Reporting by Group Practices
70.2.1 – Criteria for Determination of Satisfactory Reporting for Group Practices
and Process for Reporting under the GPRO
80 – Limitations on Review

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90 - Confidential Feedback Reports
100 – Direct Mailings

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10 - Background
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
The Physician Quality Reporting System (formerly known as Physician Quality Reporting
Initiative or PQRI) is a reporting program that provides a combination of incentive payments and
payment adjustments to identified individual eligible professionals and group practices who
satisfactorily report data on quality measures for covered professional services (defined below)
furnished by eligible professionals during a specified reporting period.
The Physician Quality Reporting System was first implemented in 2007, then referred to as
PQRI, as a result of section 101 of Division B – Medicare Improvements and Extension Act of
2006 of the Tax Relief and Health Care Act of 2006 (P.L. 109-432) (MIEA-TRHCA), which was
enacted on December 20, 2006. Section 101(b) of the MIEA-TRHCA adds subsection (k) to
section 1848 of the Social Security Act (the Act), which requires the establishment of a quality
reporting system. Section 101(c) of the MIEA-TRHCA authorizes the Secretary to provide
incentive payments to eligible professionals who satisfactorily report data on quality measures
under the quality reporting system for covered professional services furnished to Medicare
beneficiaries during the second half of 2007. CMS named the quality reporting system, the
incentive payment, and the payment adjustment the Physician Quality Reporting System.
Section 1848(k)(3)(A) of the Act defines “covered professional services” as services for which
payment is made under, or is based on, the Medicare Part B Physician Fee Schedule (PFS) and
which are furnished by an eligible professional.
Section 101(b)(1) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (P.L. 110-173)
(MMSEA), which was enacted on December 29, 2007, amends section 1848(k)(2)(B) of the Act
(as added by the MIEA-TRHCA) and section 101(c) of the MIEA-TRHCA to extend the
Physician Quality Reporting System through 2009 and to authorize the Secretary to make
incentive payments for covered Medicare PFS services furnished to Medicare Part B fee-for-
service (FFS) beneficiaries in 2008. In addition, the MMSEA amends section 101(c) of the
MIEA-TRHCA by requiring the Secretary, for 2008 and 2009, to establish alternative reporting
criteria and alternative reporting periods for reporting on measures groups, and for registry-based
reporting.
Section 131of the Medicare Improvements for Patients and Providers Act (P.L. 110-275)
(MIPPA), which was enacted on July 15, 2008, makes the quality reporting system initially
established under MIEA-TRHCA permanent. In addition, section 131(b)(2) of the MIPPA
redesignates section 101(c) of the MIEA-TRHCA, as amended by MMSEA, as subsection (m) of
section 1848 of the Act. Section 1848(m) of the Act, as redesignated and amended by the
MIPPA, authorizes the Secretary to make Physician Quality Reporting System incentive
payments for covered Medicare PFS services furnished to Medicare Part B FFS beneficiaries in
2009 and 2010.
The Affordable Care Act (ACA) makes further changes to the Physician Quality Reporting
System, including the following: authorizing incentive payments until 2014; requiring payment
adjustments beginning in 2015 for eligible professionals who do not satisfactorily report data on
quality measures during the applicable reporting period for the year; requiring timely feedback to
participating eligible professionals; requiring the establishment of an informal review process

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whereby eligible professionals may seek a review of the determination that an eligible
professional did not satisfactorily submit data on quality measures for purposes of qualifying for
a Physician Quality Reporting System incentive payment; and making available an additional
incentive payment for those eligible professionals satisfactorily reporting data on quality
measures for a year and having such data submitted on their behalf through a Maintenance of
Certification Program and participating in a Maintenance of Certification Program practice
assessment more frequently than is required to qualify for or maintain board certification status.
The program requirements for the Physician Quality Reporting System are summarized in this
chapter.
20 – Eligible Professionals
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
As defined in section 1848(k)(3)(B) of the Act, eligible professional means any of the following:
1. 	Physicians
• 	Doctor of Medicine
• 	Doctor of Osteopathy
• 	Doctor of Podiatric Medicine
• 	Doctor of Optometry
• 	Doctor of Dental Surgery
• 	Doctor of Dental Medicine
• 	Doctor of Chiropractic
2. 	Practitioners
• 	Physician Assistant
• 	Nurse Practitioner
• 	Clinical Nurse Specialist
• 	Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
• 	Certified Nurse Midwife
• 	Clinical Social Worker
• 	Clinical Psychologist
• 	Registered Dietician
• 	Nutrition Professional
• 	Audiologists (as of 1/1/2009)
3. 	Therapists
• 	Physical Therapist
• 	Occupational Therapist
• 	Qualified Speech-Language Therapist (began billing Medicare directly as of
7/1/09)
Audiologists were added to the definition of “eligible professional” beginning with the 2009
Physician Quality Reporting System as required by section 131(b)(4) of the MIPPA.

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All Medicare-enrolled professionals in these categories are eligible to participate in the Physician
Quality Reporting System, regardless of whether the professional has signed a Medicare
participation agreement to accept assignment on all claims.
20.1 – Eligible Professionals Not Able to Participate
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Some professionals who are included in the definition of “eligible professional” above, although
listed as eligible to participate in the Physician Quality Reporting System, are not able to
participate for one or more reasons described below.
Eligible professionals in certain settings in which Medicare PFS billing is processed by Medicare
FIs/AB MACs. The FI/AB MAC claims processing systems for the following settings currently
cannot accommodate billing at the individual eligible professional level:
• 	Critical access hospitals (CAHs), method II payment, where the physician or practitioner
has reassigned his or her benefits to the CAH. In this situation, the CAH bills the regular
FI or Part A MAC for the covered professional services furnished by the eligible
professional.
• 	All institutional providers that bill for outpatient therapy provided by physical and
occupational therapists and speech language pathologists (for example, hospital, skilled
nursing facility Part B, home health agency, comprehensive outpatient rehabilitation
facility, or outpatient rehabilitation facility). This does not apply to skilled nursing
facilities under Part A.
20.2 – Professionals Not Eligible to Participate in the Physician Quality
Reporting System and Not Qualified to Earn an Incentive Payment
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Providers and professionals not defined as eligible professionals are not eligible to participate in
the Physician Quality Reporting System and do not qualify for an incentive. Services payable
under fee schedules or methodologies other than the Medicare PFS are not included in the
Physician Quality Reporting System (for example, services provided in federally qualified health
centers, independent diagnostic testing facilities, portable x-ray suppliers, independent
laboratories, hospitals [including critical access], rural health clinics, ambulance providers, and
ambulatory surgery center facilities). In addition, suppliers of durable medical equipment (DME)
are not eligible for the Physician Quality Reporting System since DME is not based on or paid
under the Medicare PFS.
20.3 – Participation by Group Practices
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Prior to 2010, the Physician Quality Reporting System was limited to eligible professionals and
the determination of whether an eligible professional satisfactorily reported quality data was

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made at the individual professional level, based on the National Provider Identifier (NPI). No
incentive payments were made to a group practice based on a determination that the group
practice, as a whole, satisfactorily reported the Physician Quality Reporting System quality
measure data. To the extent that individual eligible professionals (based on individuals’ NPIs)
are associated with more than one practice, or Tax Identification Number (TIN), the
determination of whether an eligible professional satisfactorily reported the Physician Quality
Reporting System quality measures data was made for each unique TIN/NPI combination.
Therefore, the incentive payment amount was calculated for each unique TIN/NPI combination
and payment was made to the holder of the applicable TIN (see §30 below).
As required by the MIPPA, group practices can qualify to earn a Physician Quality Reporting
System incentive payment beginning with the 2010 Physician Quality Reporting System based
on the determination that the group practice, as a whole, satisfactorily reports Physician Quality
Reporting System quality measures data. The criteria for satisfactory reporting for group
practices and the process for reporting by group practices under the Physician Quality Reporting
System group practice reporting option (GPRO) are discussed in §70.3 below. In 2010,” group
practice” was defined as a TIN with at least 200 individual eligible professionals (as identified
by NPIs) who have reassigned their billing rights to the TIN.
In 2011, the GPRO was expanded to include a second, smaller GPRO classification, GPRO II.
Thus, whereas GPRO I consists of group practices comprised of a TIN with at least 200
individual eligible professionals, under GPRO II, a “group practice” is defined as a TIN with 2-
199 eligible professionals. Therefore, in 2011, due to the addition of the GPRO II to the
Physician Quality Reporting System, for purposes of this reporting option, “group practice” was
defined as a TIN with at least 2 individual eligible professionals (as identified by NPIs) who
have reassigned their billing rights to the TIN.
In 2012, the definition of GPRO was further revised. First, the GPRO II option, along with its
reporting requirements, was eliminated. In lieu of GPRO II, the GPRO (classified as GPRO I in
2011) was extended to group practices comprised of a TIN with at least 25 or more eligible
professionals. Therefore, effective beginning January 1, 2012, “group practice” is defined as a
TIN with at least 25 eligible professionals (as identified by NPIs) who have reassigned their
billing rights to the TIN.
In order to participate in the Physician Quality Reporting System GPRO, group practices are
required to complete a self-nomination process and to meet certain specified requirements, which
include but are not limited to:
• 	Indicating group size to determine eligibility to participate in the GPRO
• 	Agreeing to attend and participate in all mandatory training sessions;
• 	Have billed Medicare Part B during a specified timeframe;

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• 	Providing CMS with an electronic file (such as, a Microsoft ® Excel file) with the self-
nomination statement that includes the group practice’s TIN and all rendering individual
NPI numbers, and name of the group practice;
• 	Providing a single point of contact for handling administrative issues as well as a single
point of contact for technical support purposes; and
• 	If desired, indicating the group practice’s participation in the eRx Incentive Program for
the applicable program year with either the intended reporting method or, if applicable, a
request for a hardship exemption from the applicable eRx payment adjustment.
The specific self-nomination requirements for the Physician Quality Reporting System GPRO
for a particular program year can be found in the Group Practice Reporting Option section of the
CMS Physician Quality Reporting System website at http://www.cms.gov/PQRS.
CMS assesses whether the participation requirements are met by each self-nominated group
practice and notifies group practices of a decision. Under section 1848(m)(3)(C)(iii) of the Act,
an individual eligible professional who is a member of a group practice selected to participate in
the Physician Quality Reporting System GPRO for a particular program year is not eligible to
separately earn a Physician Quality Reporting System incentive payment as an individual eligible
professional under that same TIN (that is, for the same TIN/NPI combination) for that year.
Once a group practice (TIN) is selected to participate in the GPRO for a particular program year,
this is the only Physician Quality Reporting System reporting option available to the group and
all individual NPIs who bill Medicare under that group’s TIN for that program year.
30 – Payment for Reporting
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
A participating individual eligible professional or group practice (see §20 above) who
satisfactorily reports data on Physician Quality Reporting System quality measures as described
in §70 may earn an incentive payment equal to the applicable quality percent of the Secretary’s
estimate of allowed part B charges for covered professional services furnished by the eligible
professional or group practice during a specified reporting period (see §40 below).
For 2007 and 2008, the applicable quality percent is 1.5% incentive.
For 2009, the applicable quality percent is 2.0%.
For 2010, the applicable quality percent is 2.0%.
For 2011, the applicable quality percent is 1.0%.
For 2012 through 2014, the applicable quality percent is 0.5%.

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In addition, from 2011 through 2014, eligible professionals who are physicians may qualify to
earn an additional Maintenance of Certification Program incentive (the applicable quality percent
for each year is 0.5%). To earn this additional incentive payment, each year, a physician must:
• 	Satisfactorily submit data on quality measures (i.e. meet the criteria for satisfactory
reporting to earn a Physician Quality Reporting System reporting incentive) for the 12-
month reporting that applies for the year;
• 	Have such data submitted on their behalf through a Maintenance of Certification
Program that meets the criteria for registry (as specified by CMS) or an alternative form
and manner determined appropriate by the Secretary;
• 	Participate in a Maintenance of Certification Program more frequently than is required to
qualify for or maintain board certification status; and
• 	Successfully complete a qualified Maintenance of Certification Program practice
assessment more frequently than is required to qualify for or maintain Board certification
status.
For each year, the Physician Quality Reporting System incentive payment is calculated based on
an eligible professional’s a group practice’s total estimated Medicare Part B PFS allowed
charges for all covered professional services: (1) furnished during the applicable reporting
period, (2) received into the CMS National Claims History (NCH) file by no later than 2 months
after the end of the reporting period, and (3) paid under or based upon the Medicare PFS.
Because claims processing times may vary by time of the year and Medicare Carrier/AB MAC,
participating eligible professionals or group practices should submit claims from the end of a
reporting period promptly, so that if, for example, the reporting period ends on December 31 st of
a particular year, claims from the end of the reporting period will reach the NCH file by February
28th of the following year. Physician Quality Reporting System incentive payments are paid as a
lump sum. Physician Quality Reporting System incentive payments are generally made in the
middle of the year following the year in which the reporting period falls. There is no beneficiary
co-payment or notice to the beneficiary regarding the Physician Quality Reporting System
incentive payments.
The Physician Quality Reporting System incentive payment amount is calculated using estimated
allowed charges for all covered professional services under the Medicare Part B PFS, not just
those charges associated with reported quality measures. The term “allowed charges” refers to
total charges. Note that the amounts billed above the Medicare Part B PFS amounts for assigned
and non-assigned claims do not apply to the incentive payment. The statute defines Physician
Quality Reporting System covered professional services as those paid under or based upon the
Medicare Part B PFS only, which includes technical components of diagnostic services and
anesthesia services, as anesthesia services are considered fee schedule services though based on a
different methodology.
Other Part B services and items that may be billed by eligible professionals but are not paid
under or based upon the Medicare PFS do not apply to the Physician Quality Reporting System

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incentive payment. In addition, any amounts owed to CMS, such as from overpayments or other
withholds, are subtracted from the incentive payment amount.
The analysis of satisfactory reporting is performed at the individual eligible professional level
using individual-level NPI data, and beginning in 2010, for group practices participating in the
GPRO, the group practice level using TIN data. For both participating individual eligible
professionals and group practices, CMS uses the TIN as the billing unit. Therefore, any
Physician Quality Reporting System incentive payments earned are paid to the TIN holder of
record. For individual eligible professional, Physician Quality Reporting System incentive
payments are paid to the holder of the TIN, aggregating individual incentive payments for groups
that bill under one TIN. For eligible professionals who submit claims under multiple TINs, CMS
groups claims by TIN for payment purposes. As a result, a provider with multiple TINs who
qualifies for the Physician Quality Reporting System incentive payment under more than one
TIN would receive a separate Physician Quality Reporting System incentive payment associated
with each TIN.
In situations where eligible professionals are employees or contractors who have assigned their
payments to their employers or facilities, section 1848(m)(1)(A) of the Act specifies that any
Physician Quality Reporting System incentive payment earned be paid to the employers or
facilities.
40 – Reporting Period
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For the 2007 Physician Quality Reporting System, which was the first program year, the
reporting period was July 1, 2007 through December 31, 2007, as required by section
1848(m)(6)(C)(i)(I) of the Act.
For 2008 and beyond, section 1848(m)(6)(C)(i)(II) of the Act defines “reporting period” to be
the entire calendar year. Under section 1848(m)(6)(C)(ii) of the Act, however, for years after
2009, the Secretary is authorized to revise such reporting periods. In addition, section
1848(m)(5)(F) of the Act requires the Secretary to, beginning with the 2008 Physician Quality
Reporting System, establish alternative reporting periods for reporting groups of measures, or
measures groups, and for reporting using a medical registry.
Therefore, beginning with the 2008 Physician Quality Reporting System, there are 2 reporting
periods for each program year: (1) a 12-month reporting period consisting of the entire calendar
year and (2) a 6-month reporting period beginning July 1st and ending December 31 st .
Depending upon the particular program year, the second reporting period beginning July 1 st may
not apply to all of the Physician Quality Reporting System reporting options that are available
for that program year (see §70 below for further details).
50 – Form and Manner of Reporting
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)

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Eligible professionals may choose to report quality measures data to CMS using one of the
following established reporting mechanisms:
• 	Claims-based reporting;
• 	Registry-based reporting (beginning in 2008): or
• 	EHR-based reporting (beginning in 2010).
Beginning with the 2007 Physician Quality Reporting System, CMS implemented the claims-
based reporting mechanism based on submission of quality measures data on Medicare Part B
claims.
The registry-based reporting mechanism became available to eligible professionals beginning
with the 2008 Physician Quality Reporting System. The registry-based reporting mechanism is
available for reporting either individual Physician Quality Reporting System quality measures or
Physician Quality Reporting System measures groups (see §60.1 and §60.2, respectively)
The EHR-based reporting mechanism became available to eligible professionals beginning with
the 2010 Physician Quality Reporting System and is available for reporting on individual
Physician Quality Reporting System quality measures only (see §60.1 below).
50.1 – Claims-based Reporting Mechanism
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Eligible professionals who choose to participate in Physician Quality Reporting System via the
claims-based reporting mechanism do not have to enroll or register with CMS to begin reporting
Physician Quality Reporting System quality measures data to CMS.
Participating eligible professionals whose Medicare patients fit the specifications of the
Physician Quality Reporting System quality measures and/or measures groups will simply report
on their claims the corresponding appropriate quality-data codes (QDCs), which are CPT
Category II codes or G-codes (where CPT Category II codes are not yet available). CPT
Category II codes and G-codes are Healthcare Common Procedure Coding System (HCPCS)
codes for reporting quality data. Claims-based reporting may be via: (1) the paper-based CMS
1500 Claim form or (2) the equivalent electronic transaction claim, the 837-P.
50.1.1 – Coding and Reporting Principles for Claims-based Reporting
(Rev. 82, Issued: 03-22-19, Effective: 04-22-19, Implementation: 04-22-19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's
Medicare identification number. For purposes of this manual, Medicare beneficiary identifier
references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary
Identifier (MBI) during the new Medicare card transition period and after for certain business
areas that will continue to use the HICN as part of their processes.

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The following principles apply to the reporting of QDCs for Physician Quality Reporting System
measures:
• 	The CPT Category II code(s) and/or G-code(s), which supply the numerator, must be
reported:
o 	on the same claim(s) as the denominator billing code(s) for the same date of service
(DOS)
o 	for the same beneficiary
o 	for the same date of service (DOS)
o 	by the same eligible professional (individual NPI) who performed the covered service
as the payment codes, usually ICD diagnosis , CPT Category I or HCPCS codes,
which supply the denominator.
• 	All diagnoses reported on the claim will be included in Physician Quality Reporting
System analysis, as some Physician Quality Reporting System measures require reporting
more than one diagnosis on a claim. For line items containing a QDC, only a single
reference number in the diagnosis pointer field will pass into the NCH file. To report a
QDC for a measure that requires reporting of multiple diagnoses, enter the reference
number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses
listed on the base claim. Regardless of the reference number in the diagnosis pointer
field, both primary and all secondary diagnoses (base claim diagnoses) are considered in
Physician Quality Reporting System analysis.
• 	Up to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim
and up to eight diagnoses can be reported in the header on the electronic claim. However,
only one diagnosis can be linked to each line item, whether billing on paper or
electronically. The Physician Quality Reporting System analyzes claims data using ALL
diagnoses from the base claim (the ASC X12 837 professional claim format or Item 21 of
the Form CMS-1500) and service codes for each individual professional identified by his
or her rendering individual NPI. In other words, base claim diagnoses apply to all
rendering TIN/NPIs on the claim. Eligible professionals should review ALL diagnosis
and encounter codes listed on the claim to make sure they are capturing ALL reported
measures applicable to that patient’s care.
• 	If the eligible clinician’s billing software limits the number of line items available on a
claim, an eligible clinician may add a nominal amount such as a penny, to one of the line
items on that second claim for a total charge of one penny. CMS will look across all
claims data for common occurrences of A/B MAC (B) claim control numbers, Medicare
beneficiary identifiers, and A/B MAC (B) numbers.
Only final action claims will be analyzed for Physician Quality Reporting System. For
Physician Quality Reporting System measure calculation purposes, claims will be combined
based on the same beneficiary for the same date-of-service, for the same TIN/NPI and

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analyzed as one claim. Providers should work with their billing software
vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses or QDCs
are not dropped.
• 	QDCs must be submitted with a line-item charge of zero dollars ($0.00) at the time the
associated covered professional service is performed.
o 	The submitted charge field cannot be blank.
o 	The line item charge should be $0.00.
o 	If an eligible professional’s billing software does not allow a $0.00 line-item charge,
a nominal amount can be substituted such as 1 penny ($0.01) – the beneficiary is not
liable for this nominal amount.
o 	Entire claims with a zero charge will be rejected. (Total charge for the claim cannot
be $0.00.)
o 	Whether a $0.00 charge or a nominal amount is submitted to the A/B MAC (B), the
Physician Quality Reporting System QDC code line is denied and tracked.
• 	QDC line items will be denied for payment, but are then passed through the claims
processing system for Physician Quality Reporting System analysis. Eligible professionals
will receive a Remittance Advice (RA) associated with the claim which will contain the
Physician Quality Reporting System quality-data code line-item and will include a standard
remark code (N365) and a message that confirms that the QDCs passed into the NCH file.
N365 reads: “This procedure code is not payable. It is for reporting/information purposes
only.” The N365 remark code does NOT indicate whether the QDC is accurate for that claim
or for the measure the eligible professional is attempting to report.
o 	Keep track of all Physician Quality Reporting System cases reported so that the
eligible professionals can verify QDCs reported against the remittance advice notice
sent by the A/B MAC (B). Each QDC line-item will be listed with the N365 denial
remark code.
• 	Multiple eligible professionals’ QDCs can be reported on the same claim using their
individual NPI. Therefore, when a group is billing, the group should follow its normal billing
practice of placing the NPI of the individual eligible professional who rendered the service
on each line item on the claim including the QDC line(s).
• 	Some measures require the submission of more than one QDC in order to properly report the
measure. Eligible professionals may report each QDC as a separate line item, referencing one
diagnosis and including the rendering provider NPI.

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• 	Use of CPT II modifiers (1P, 2P, 3P, 8P) is unique to CPT II codes and may not be used with
other types of CPT codes. Only CPT II modifiers may be appended to CPT II codes. Do not
append CPT I modifiers to CPT II codes or vice versa.
• 	Solo practitioners should follow their normal billing practice of placing their individual NPI
in the billing provider field, (on the ASC X12 837 professional claim format or item 33b on
the Form CMS-1500).
• 	Eligible professionals may submit multiple codes for more than one measure on a single
claim.
• 	Multiple CPT Category II and/or G-codes for multiple measures that are applicable to a
patient visit can be reported on the same claim, as long as the corresponding denominator
codes are also line items on that claim.
• 	If a denied claim is subsequently corrected through the appeals process to the A/B MAC (B),
with accurate codes that also correspond to the measure’s denominator, then QDCs that
correspond to the numerator should also be included on the resubmitted claim as instructed in
the measure specifications.
• 	Claims may NOT be resubmitted for the sole purpose of adding or correcting QDCs.
• 	Eligible Professionals should use the 8P reporting modifier judiciously for applicable
measures they have selected to report. The 8P modifier may not be used indiscriminately in
an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s
quality improvement goals.
Submission through A/B MACs (B)
QDCs shall be submitted to A/B MACs (B) either through:
Electronic submission, which is accomplished using the current version of the ASC X12 837
professional claim format.
CPT Category II and/or temporary G-codes should be submitted in the SV101-2
“Product/Service ID” Data Element on the SV1 “Professional Service” Segment of the 2400
“Service Line” Loop.
• 	It is also necessary to identify in this segment that a HCPCS code (HC) is being supplied
by submitting the HC in data element SV101-1 within the SV1 “Professional Service”
Segment.
• 	Diagnosis codes are submitted at the claim level, Loop 2300, in data element HI01, and
if there are multiple diagnosis codes, in HI02 through HI12 as needed with a single
reference number in the diagnosis pointer.

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• 	In general for group billing, report the NPI for the rendering provider in Loop 2310B
(Rendering Provider Name, claim level) or 2420A (Rendering Provider Name, line level),
using data elements NM109 (NM108=XX).
OR
Paper-based submission, which is accomplished by using the Form CMS-1500 claim (version
02-12). Relevant diagnosis codes are entered in Field 21. Service codes (including CPT,
HCPCS, CPT Category II and/or G-codes) with any associated modifiers are entered in Field
24D with a single reference letter in the diagnosis pointer Field 24E that corresponds with the
diagnosis letter in Field 21.
• 	For group billing, the National Provider Identifier (NPI) of the rendering provider is
entered in Field 24J.
• 	The Tax Identification Number (TIN) of the employer is entered in Field 25.
Group NPI Submission
When a group bills, the group’s NPI is submitted at the claim level, therefore, the individual
rendering physician’s NPI must be placed on each line item, including all allowed charges and
quality-data line items.
Individual NPI Submission
The individual NPI of the solo practitioner must be included on the claim line as is the normal
billing process for submitting Medicare claims. For the Physician Quality Reporting System, the
QDC must be included on the same claim that is submitted for payment at the time the claim is
initially submitted in order to be included in Physician Quality Reporting System analysis.
Form CMS-1500 Claim Example
An example of a claim in CMS-1500 format that illustrates how to report several Physician
Quality Reporting System measures is available in the Physician Quality Reporting System
Implementation Guide, a downloadable document that is updated for each program year and
posted on the CMS Physician Quality Reporting System website http://www.cms.hhs.gov/PQRS.
Satisfactorily Reporting Measures
Physician Quality Reporting System participants should also refer to the “How to Get Started”
section of the Physician Quality Reporting System website, available at
http://www.cms.gov/PQRS. This section provides helpful information on how to get started with
reporting quality measures for the Physician Quality Reporting System.
Timeliness of Quality Data Submission
Claims processed by the A/B MAC (B) must reach the National Claims History (NCH) file by no
later than 2 months after the end of the reporting period to be included in the analysis. For the
2010 Physician Quality Reporting System, for example, claims processed by the A/B MAC (B)
must reach the NCH file by no later than February 28, 2011 to be included in the analysis.
Claims for services furnished toward the end of the reporting period should be filed promptly.

15
Claims that are resubmitted only to add QDCs will not be included in the analysis for Physician
Quality Reporting System.
50.2 – Registry-based Reporting Mechanism
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Beginning in 2008, Individual eligible professionals may choose to participate in the Physician
Quality Reporting System via the registry-based reporting mechanism. Eligible professionals who
choose to participate in the Physician Quality Reporting System via the registry-based reporting
mechanism do not have to enroll or register to begin registry-based reporting of Physician Quality
Reporting System quality measures data to CMS. However, t o report Physician Quality Reporting
System quality measures data via the registry-based reporting mechanism, an eligible
professional must select a registry qualified under the Physician Quality Reporting System for
the program year and enter into and maintain an appropriate legal arrangement with the selected
registry. Such arrangements should provide for the registry’s receipt of patient-specific data
from the eligible professional and the registry’s disclosure of quality measures results and
numerator and denominator data on Physician Quality Reporting System quality measures or
measures groups on behalf of the eligible professional to CMS. An eligible professional
choosing the registry-based reporting mechanism must submit information on Physician Quality
Reporting System individual quality measures or measures groups to his or her selected registry
in the form and manner and by the deadline specified by the registry. Thus the registry would
act as a Health Insurance Portability and Accountability Act of 1996 (Pub. L.104-191) (HIPAA)
Business Associate and agent of the eligible professional. Such agents are referred to as “data
submission vendors.” The “data submission vendors” would have the requisite legal authority to
provide clinical quality measures results and numerator and denominator data on individual
quality measures or measures groups on behalf of the eligible professional for the Physician
Quality Reporting System.
CMS qualifies registries to participate in each program year through a self-nomination process.
Registries that were qualified to submit data on behalf of eligible professionals in a prior
program year are not required to go through the qualification process again unless they were
unsuccessful at submitting Physician Quality Reporting System data for the prior program year
by the registry’s data submission deadline or CMS makes changes to the registry qualification
requirements. The final list of qualified registries for a particular program year is made available
on the CMS Physician Quality Reporting System website at http://www.cms.hhs.gov/PQRS.
The list is usually made available in the summer of the program year in question. For example,
the list of qualified registries for the 2008 Physician Quality Reporting System was made
available in the summer of 2008.
50.3 – Electronic Health Record-based (EHR-based) Reporting Mechanism
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
To report Physician Quality Reporting System quality measures data via a direct EHR-based
reporting mechanism, an eligible professional must select a qualified direct EHR product. For
each program year, an eligible professional choosing the EHR-based reporting mechanism must:

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• 	Have access to a CMS-specified identity management system, such as IACS;
• 	Submit a test file containing dummy clinical quality data extracted from the EHR to a
CMS clinical data warehouse; and
• 	Submit a file containing the eligible professional’s Physician Quality Reporting System
clinical quality data extracted from the EHR for the entire reporting via the CMS-
designated clinical data warehouse by no later than 2 months after the end of the
reporting period
CMS qualifies EHR vendors and their specific product(s) for use by eligible professionals to
submit Physician Quality Reporting System quality measures data to CMS. The list of qualified
EHR vendors and products for a specific program year are made available on the CMS Physician
Quality Reporting System website at http://www.cms.hhs.gov/PQRS. The list of qualified EHR
vendors and products is generally posted before the start of program year or shortly thereafter.
For example, the list of 2011 qualified EHR vendors and products was posted prior to January
2011.
To report Physician Quality Reporting System quality measures data via an EHR data
submission vendor, an eligible professional must select a qualified EHR data submission vendor
product.
60 – Physician Quality Reporting System Measures
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
To qualify to earn the Physician Quality Reporting System incentive payment, an eligible
professional must report data on quality measures. Beginning with the 2008 Physician Quality
Reporting System, eligible professionals have the option of reporting data on individual quality
measures or on measures groups. Physician Quality Reporting System measures groups are
created by CMS by grouping 4 or more Physician Quality Reporting System measures that have
a clinical condition or focus in common. The Physician Quality Reporting System measures that
comprise a measures group share a common denominator specification and therefore differ in
their specifications from that of individual measures.
60.1 – Reporting of Individual Physician Quality Reporting System Quality
Measures
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
When the Physician Quality Reporting System was first implemented in 2007, the program
consisted of 74 individual quality measures, all of which were reportable via the claims-based
reporting mechanism only.
In 2008, CMS retired some of the 2007 measures but added new measures so that the total
number of Physician Quality Reporting System individual quality measures expanded to 119.

17
The 2009 Physician Quality Reporting System included a total of 153 individual quality
measures. Data on 53 of the 2009 Physician Quality Reporting System measures may only be
reported through a qualified registry and may not be reported through claims-based reporting
(see §50 above).
The 2010 Physician Quality Reporting System includes a total of 175 individual quality
measures. Data on 10 of the 2010 Physician Quality Reporting System measures may be
reported via a qualified EHR product, however, two of these may not be reported through
claims-based reporting. In addition, data on 50 of the 2010 Physician Quality Reporting System
measures may not be reported through claims-based reporting. Such data must be reported
through a qualified registry, or if the measure is 1 of the 10 measures designated for EHR
reporting, via a qualified EHR product.
The 2011 Physician Quality Reporting System included a total of 190 individual quality
measures that may be reported via claims, registry, and/or EHR.
The 2012 Physician Quality Reporting System includes a total of 224 individual quality
measures that may be reported via claims, registry, and/or EHR. 	Note that these are some
limitations as to which measures may be reported via claims, registry and/or EHR.
A complete list of the individual Physician Quality Reporting System quality measures for a
specific program year, as well as their detailed measure specifications and respective reporting
requirements can be found on the CMS Physician Quality Reporting System website at
http://www.cms.gov/PQRS. Measure specifications for the current or upcoming program year
can be found on the Measures Codes page of the CMS Physician Quality Reporting System
website. Measure specifications for prior program years are archived to the appropriate
Physician Quality Reporting System Program page of the CMS Physician Quality Reporting
System website.
When measures for a particular program year are selected from a prior year’s measure set, the
detailed measure specifications for such measures may have been updated or modified during the
National Quality Forum endorsement process or for other reasons. The Physician Quality
Reporting System quality measure specifications for any given measure selected for use in a
specific program year may, therefore, be different from specifications for the same quality
measure used for a prior program year. For example, the 2009 Physician Quality Reporting
System specifications for a measure that was used in the 2008 Physician Quality Reporting
System may be different from the 2008 Physician Quality Reporting System specifications for
the same measure. Eligible professionals must ensure that they are using the published
specifications for the correct program year.
60.2 – Reporting of Physician Quality Reporting System Measures Groups
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For the 2008 Physician Quality Reporting System, CMS established 4 measures groups to
address the following clinical topics:
(1) Diabetes Mellitus,

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(2) Chronic Kidney Disease (CKD),
(3) Preventive Care, and
(4) End Stage Renal Disease (ESRD).
For the 2009 Physician Quality Reporting System, CMS removed the ESRD measures group, but
added 4 additional measures for a total of 7 measures groups. The 2009 Physician Quality
Reporting System measures groups address the following clinical topics:
(1) Diabetes Mellitus,
(2) CKD,
(3) Preventive Care,
(4) Coronary Artery Bypass Graft (CABG) Surgery,
(5) Rheumatoid Arthritis,
(6) Perioperative Care, and
(7) Back Pain.
For the 2010 Physician Quality Reporting System, CMS retained all of the 2009 Physician
Quality Reporting System measures groups and added 6 new measures groups for a total of 13
measures groups. The 2010 Physician Quality Reporting System measures groups address the
following clinical topics:
(1) Diabetes Mellitus,
(2) CKD,
(3) Preventive Care,
(4) CABG Surgery,
(5) Rheumatoid Arthritis,
(6) Perioperative Care,
(7) Back Pain,
(8) Coronary Artery Disease (CAD),
(9) Heart Failure,
(10) Hepatitis C,
(11) Ischemic Vascular Disease (IVD),
(12) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS),
and
(13) Community-Acquired Pneumonia (CAP).
For the 2011 Physician Quality Reporting System, CMS retained all of the 2010 Physician
Quality Reporting System measures groups and added 1 new measures group, for a total of 14
measures groups. The 2011 Physician Quality Reporting System measures groups address the
following clinical topics:
(1) Diabetes Mellitus,
(2) CKD,
(3) Preventive Care,
(4) CABG Surgery,
(5) Rheumatoid Arthritis,
(6) Perioperative Care,

19
(7) Back Pain,
(8) Coronary Artery Disease (CAD),
(9) Heart Failure,
(10) Hepatitis C,
(11) Ischemic Vascular Disease (IVD),
(12) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS),
and
(13) Community-Acquired Pneumonia (CAP).
(14) Asthma
For the 2012 Physician Quality Reporting System, CMS retained all of the 2011 Physician
Quality Reporting System measures groups and added 8 new measures groups, for a total of 22
measures groups. The 2012 Physician Quality Reporting System measures groups address the
following clinical topics:
(1) Diabetes Mellitus,
(2) CKD,
(3) Preventive Care,
(4) CABG Surgery,
(5) Rheumatoid Arthritis,
(6) Perioperative Care,
(7) Back Pain,
(8) Coronary Artery Disease (CAD),
(9) Heart Failure,
(10) Hepatitis C,
(11) Ischemic Vascular Disease (IVD),
(12) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS),
(13) Community-Acquired Pneumonia (CAP),
(14) Asthma,
(15) COPD,
(16) IBD,
(17) Sleep Apnea,
(18) Dementia,
(19) Parkinson’s,
(20) Elevated Blood Pressure,
(21) Cardiovascular Prevention, and
(22) Cataracts.
In addition, all measures contained in the following 2012 Physician Quality Reporting System
measures groups are also reportable as individual measures:
(1) Diabetes Mellitus,
(2) CKD,
(3) Preventive Care,
(4) CABG Surgery,
(5) Rheumatoid Arthritis,
(6) Perioperative Care,

20
(7) Coronary Artery Disease (CAD),
(8) Heart Failure,
(9) Hepatitis C,
(10) Ischemic Vascular Disease (IVD),
(11) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS),
(12) Community-Acquired Pneumonia (CAP),
(13) Asthma,
(14) COPD, and
(15) Cardiovascular Prevention.
In addition, data on the CABG, CAD, Heart Failure, HIV/AIDS, IBD, Sleep Apnea, Dementia,
Parkinson’s, Elevated Blood Pressure, and Cataracts measures groups may only be reported
through a qualified registry and may not be reported through claims-based reporting (see §50
above).
Measures groups specifications are different from the specifications for individually reported
measures (if any measures in a measures group may be reported individually) that form the
group. Therefore, the specifications, including the list of measures selected for inclusion in each
of the Physician Quality Reporting System measures groups, and reporting instructions for the
Physician Quality Reporting System measures groups are provided separately from the
specifications for the individual Physician Quality Reporting System measures. The
specifications manual for measures groups can be found on the CMS Physician Quality
Reporting System website at http://www.cms.hhs.gov/PQRS. Measures group specifications for
the current or upcoming program year can be found on the Measures Codes page of the CMS
PQRS website. Measures group specifications for prior program years are archived to the
appropriate Physician Quality Reporting System Program page of the CMS Physician Quality
Reporting System website.
To initiate claims-based reporting of measures groups, it is necessary that the eligible
professionals indicate the intention to begin reporting a measures group by submitting a
measures group-specific G-code on the patient claim. There is one defined measures group-
specific G-code for each Physician Quality Reporting System measures group. It is not
necessary to submit the measures group-specific G-code on more than one claim. If the
measures group-specific G-code for a given group is submitted multiple times during the
reporting period, only the submission with the earliest date of service will be included in the
Physician Quality Reporting System analyses; subsequent submissions of that code will be
ignored. It is not necessary to submit the measures-group specific G-code for registry-based
submissions. In addition, beginning for the 2009 Physician Quality Reporting System, if all
quality actions for the applicable measures in a measures group have been performed for the
patient, one Physician Quality Reporting System composite G-code may be reported in lieu of
the individual quality-data codes for each of the measures within the group. There is one defined
composite G-code for each Physician Quality Reporting System measures group.
Similar to the specifications for individual Physician Quality Reporting System measures, when
measures groups for a particular program year are selected from a prior year’s measures group
set, the detailed measures group specifications for such a measures group may have been updated
or modified during the National Quality Forum endorsement process or for other reasons. In

21
addition, the individual measures that comprise a specific measures group may change from year
to year. Therefore, the Physician Quality Reporting System measures group specifications for
any given measures group selected for use in a specific program year may be different from
specifications for the same measures group used for a prior program year. For example, the
measures that form the Diabetes Mellitus and CKD measures groups for the 2009 Physician
Quality Reporting System are different from the measures that were included in these measures
groups for 2008.
Not only do eligible professionals need to ensure that they are using the measures groups
specifications rather than the specifications for the individual Physician Quality Reporting
System measures, but eligible professionals also must ensure that they are using the measures
groups specifications for the correct program year.
70 – Criteria for Determination of Satisfactory Reporting
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In order to qualify to earn a Physician Quality Reporting System incentive payment, eligible
professionals and group practices must meet the criteria for satisfactorily reporting data on
Physician Quality Reporting System quality measures. The criteria that are applicable depend on
whether participation is at the individual eligible professional level or at the group practice level
and may differ from one program year to another.
70.1 – Criteria for Determination of Satisfactory Reporting of Individual
Measures and Measures Groups for Individual Eligible Professionals
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For eligible professionals participating in the Physician Quality Reporting System at the
individual eligible professional level, the criteria for satisfactory reporting differ depending on
the reporting period an eligible professional chooses to report, the manner in which an eligible
professional reports (whether the eligible professional chooses the claims-based, registry-based,
or EHR-based reporting mechanism), and whether an eligible professional chooses to report on
individual quality measures or on measures groups.
For the 2007 Physician Quality Reporting System, there was only 1 reporting option and a single
reporting period that an eligible professional could use to attempt to satisfactorily report quality
measures. There was no option of reporting on measures groups, or reporting through a qualified
registry or qualified EHR.
In 2008, with the introduction of registry-based reporting, reporting on measures groups, and
alternative reporting periods for the Physician Quality Reporting System, multiple reporting
options became available.
For the 2008 Physician Quality Reporting System, there were a total of 9 reporting options. For
the 2009 Physician Quality Reporting System, 9 reporting options were also available but there
were some differences between the 2008 Physician Quality Reporting System reporting options
and the 2009 Physician Quality Reporting System reporting options.

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For the 2010 Physician Quality Reporting System, 11 reporting options are available.
For the 2011 Physician Quality Reporting System, there were still 11 reporting options available.
However, there are some differences between the 2010 Physician Quality Reporting System
reporting options and the 2011 Physician Quality Reporting System reporting options. To
qualify for a Physician Quality Reporting System incentive payment for a particular program
year, each eligible professional must ensure that he or she meets the criteria for satisfactory
reporting for the relevant reporting period, relevant reporting mechanism, and for reporting either
individual measures or measures groups, as appropriate.
For the 2012 Physician Quality Reporting System, there are a total of 9 reporting options that an
individual eligible professional could use to attempt to satisfactorily report quality measures.
The change in the number of reporting options from 11 in 2011 to 9 in 2012 is due to the
following factors: (1) the elimination of the 6-month reporting period, except for reporting on
measures groups via registry and (2) adoption of an additional reporting option for EHR-based
reporting that aligns with the criteria for meeting the clinical quality measure objective for
achieving meaningful use under the Medicare EHR Incentive Program in 2012.
Although there are multiple reporting options for satisfactory reporting, an eligible professional
only needs to satisfactorily report under one option for a specific program year to qualify for the
incentive payment applicable to a reporting period for the program year. An eligible
professional who qualifies for more than one reporting period for a particular program year will
receive the incentive payment for the longest reporting period for which the professional
qualifies for that program year. Only one incentive payment per program year may be obtained
regardless of how many reporting options the eligible professional chooses.
For purposes of determining satisfactory reporting, if an eligible professional attempts to submit
data for a quality measure or measures group at least once, then the measure or measures group
is presumed to be applicable to the eligible professional. Eligible professionals are responsible
for selecting the quality measures and/or measures groups that are applicable to their practices.
70.1.1 – Criteria for Determination of Satisfactory Reporting of Individual
Measures for Claims-based Reporting
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
As discussed in §60 above, eligible professionals have the option of reporting on individual
quality measures or on measures groups. The criteria for determining whether an eligible
professional satisfactorily reports data on Physician Quality Reporting System quality measures
for reporting individual quality measures are different from the criteria for satisfactory reporting
of measures groups.
To qualify for a Physician Quality Reporting System incentive payment through claims-based
reporting of individual measures prior to the 2011 program year, each eligible professional must
meet the following criteria for satisfactory reporting during the applicable reporting period:

23
• 	Report at least 3 Physician Quality Reporting System measures for the relevant program
year, or 1-2 measures, if less than 3 measures apply to an eligible professional; and
• 	Report each measure on at least 80 % of the Medicare Part B FFS patients to whom the
measure applies.
For years prior to the 2011 Physician Quality Reporting System, if an eligible professional
reports less than 3 measures, the eligible professional must:
• 	Report on all measures that apply to the services furnished by the professional, and
• 	Report each measure for at least 80% of the eligible professional’s Medicare Part B FFS
patients for whom services were furnished during the reporting period to which the
measure(s) applies.
The eligible professional may also be subject to a Measure Applicability Validation (MAV)
process, which would allow CMS to determine whether an eligible professional should have
reported QDCs for additional measures.
For the 2007 Physician Quality Reporting System, these criteria applied to the 6-month reporting
period beginning July 1 st only.
For the 2008 and 2009 Physician Quality Reporting System, these criteria applied to the 12-
month reporting period beginning January 1st only.
For the 2010 Physician Quality Reporting System, these criteria apply to both the 12-month
reporting period beginning January 1st and the 6-month reporting period beginning July 1st for
claims-based reporting of individual measures. This results in a total of 2 reporting options for
claims-based reporting of individual measures for the 2010 Physician Quality Reporting System.
The 2011 Physician Quality Reporting System retained the 2 reporting options established in the
2010 Physician Quality Reporting System. However, the 2011 Physician Quality Reporting
System reduced the percentage of instances eligible professionals must report per measure.
Eligible professionals need only report on 50% instead of 80% of the Medicare Part B FFS
patients to whom each measure applies.
The 2012 Physician Quality Reporting System retains 1 of the 2 reporting options established in
the 2011 Physician Quality Reporting System. The reporting option established for a 6-month
reporting period was eliminated. In addition, under all 2012 claims-based reporting options for
the 2012 Physician Quality Reporting System, measures reported with a zero percent
performance rate will not be counted.
The 2012 Physician Quality Reporting System criteria for satisfactorily reporting individual
quality measures through claims-based reporting that each eligible professional must meet under
these 2 reporting options are summarized in Table 1 below along with the relevant reporting
period for each reporting option.

24
Table 1: 2012 Criteria for Satisfactory Reporting of Individual Quality Measures through
Claims
Reporting Criteria 	Reporting Period
• 	Report at least 3 Physician Quality Reporting System
measures, or
• 	1-2 measures if less than 3 measures apply to an EP; and
• 	Report each measure for at least 50% of Medicare Part B
FFS patients to whom the measure applies.
If reporting less than 3 measures, the eligible professional must:
• 	Report on all measures that apply to the services
furnished by the professional, and
• 	Report each measure for at least 50% of the eligible
professional’s Medicare Part B PFS patients for whom
services were furnished during the reporting period to
which the measure(s) applies.
• 	May also be subject to a MAV process
January 1, 2012–
December 31, 2012
Eligible professionals who report on fewer than three individual Physician Quality Reporting
System individual quality measures may be subject to a two-step measure-applicability
validation (MAV) process. The purpose of the MAV is to determine whether the eligible
professional should have submitted quality-data codes for additional measures. If CMS finds
that eligible professionals who have reported fewer than three quality measures have not reported
additional measures that are also applicable to the services they furnished during the reporting
period, then those eligible professionals cannot earn the incentive payment. More information
on the MAV process for a specific program year is available in the Analysis and Payment section
of the CMS PQRS website at http://www.cms.hhs.gov/PQRS.
When claims-based reporting of measures groups was introduced in the 2008 Physician Quality
Reporting System program, the only reporting period available for claims-based reporting of
measures groups was the 6-month reporting period beginning July 1, 2008. However, there were
2 reporting options for claims-based reporting of measures groups for 2008. The first reporting
option for claims-based reporting of measures groups for the 2008 Physician Quality Reporting
System consisted of the following criteria for satisfactory reporting:
• 	Report at least 1 measures group; and
• 	Report each measure in the measures group on at least 15 consecutively seen Medicare
Part B FFS patients to whom the measures in the measures group apply for each
participating eligible professional.
The term “consecutive” refers to the manner in which the patients are seen by the eligible
professional and are selected for inclusion in the eligible professional’s patient sample. The
patient sample must consist of at least 15 unique Medicare Part B FFS patients seen
consecutively, or in order, by date of service, by the eligible professional.

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The second reporting option for claims-based reporting of measures groups for the 2008
Physician Quality Reporting System consisted of the following criteria for satisfactory reporting:
• 	Report at least 1 measures group; and
• 	Report each measure in the measures group on at least 80% of Medicare Part B FFS
patients for whom the measures in the measures group apply for each participating
eligible professional.
Beginning with the 2009 Physician Quality Reporting System, CMS implemented two reporting
periods for claims-based reporting of measures groups: a 12-month reporting period beginning
January 1st and a 6-month reporting period beginning July 1st.
For the 2009 Physician Quality Reporting System, there were 3 reporting options for claims-
based submission of measures groups. Whereas for the 2008 Physician Quality Reporting
System only the 6-month reporting period was available for claims-based submission of
measures groups, both the 12-month and the 6-month reporting periods are available for claims-
based submission of measures groups for the 2009 Physician Quality Reporting System. In
addition, CMS eliminated the option of reporting on at least one measures group on 15
consecutive patients for the 6-month reporting period but added the option of reporting on at
least 30 consecutive Medicare Part B FFS patients during the 12-month reporting period instead.
We also added a minimum sample size requirement for eligible professionals reporting on at
least 80% of applicable Medicare Part B FFS patients. Eligible professionals reporting on 80%
of applicable Medicare Part B FFS patients for the 12-month reporting period must have at least
30 applicable patients. Eligible professionals reporting on 80% of applicable Medicare Part B
FFS patients for the 6-month reporting period must have at least 15 applicable patients.
CMS implemented the following changes to the 2009 Physician Quality Reporting System for
the 2010 Physician Quality Reporting System: (1) eliminated the requirement that the 30
patients be seen consecutively to allow an eligible professional to report on any 30 patients seen
at any time during the reporting period; and (2) reduced the minimum patient sample size
threshold for eligible professionals reporting on at least 80% of applicable Medicare Part B FFS
patients to 15 and 8 for the 12-month and 6-month reporting periods, respectively.
With respect to the reporting options for claims-based submission of measures groups, the 2011
Physician Quality Reporting System is largely identical to the 2010 Physician Quality Reporting
System. However, CMS implemented the following change in 2011: eligible professionals need
only report at least 50% (instead of the 80% that was required in the 2010 Physician Quality
Reporting System) of their Medicare Part B FFS patients seen during the reporting period to
which the measures group applies.
For the 2012 Physician Quality Reporting System, CMS retained the two 2011 reporting options
for the 12-month reporting period. However, CMS implemented the following change for 2012:
measures within a measures group with a zero percent performance rate will not be counted.
Therefore, the 2012 Physician Quality Reporting System criteria for satisfactorily reporting
measures groups through claims-based reporting that each eligible professional must meet under

26
these 2 reporting options are summarized in Table 2 below along with the relevant reporting
period for each reporting option.
Table 2: 2012 Criteria for Satisfactory Reporting of Measures Groups through Claims
Reporting Criteria 	Reporting Period
• 	Report at least one measures group; and
• 	Report each measure within the measures group for at
least 30 Medicare Part B FFS patients to whom the
measures group apply
• 	Measures within a measures group with a zero percent
performance rate will not be counted.
January 1, 2012 –
December 31, 2012
• 	Report at least one measures group; and
• 	Report each measure within the measures group for at
least 50% of Medicare Part B FFS patients to whom the
measures in the measures group apply; but
• 	Report each measures group on at least 15 patients during
the reporting period for which the measures group
applies.
• 	Measures within a measures group with a zero percent
performance rate will not be counted.
January 1, 2012–
December 31, 2012
Eligible professionals choosing to participate in the Physician Quality Reporting System through
the claims-based reporting mechanism, regardless of whether they choose to report on individual
measures or measures groups, must have their own individual-level NPI and must consistently
use their individual NPI to correctly identify their services, procedures, and QDCs for an
accurate determination of satisfactory reporting. As stated in §30 above, the analysis of whether
an eligible professional has satisfactorily reported is performed at the individual eligible
professional level using the individual-level NPI. The eligible professional’s individual NPI must
be listed correctly along with the HCPCS codes for services, procedures, and QDCs on the claim.
More information on reporting options for a specific program year is available on the CMS
Physician Quality Reporting System website at http://www.cms.hhs.gov/PQRS.
70.1.2 – Criteria for Determination of Satisfactory Reporting of Individual
Measures for Registry-based Reporting
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In addition to the option of reporting on individual quality measures or on measures groups,
eligible professionals, beginning with the 2008 Physician Quality Reporting System, also have
the option of reporting Physician Quality Reporting System quality measures information to
CMS via a qualified registry instead of submitting the quality measures data on claims (see §50).
The criteria for determining whether an eligible professional satisfactorily reports data on
Physician Quality Reporting System quality measures for reporting via a registry are different
from the criteria for satisfactory reporting via claims.

27
When registry-based reporting of Physician Quality Reporting System quality measures data was
introduced in the 2008 Physician Quality Reporting System, there were two reporting periods
available for registry-based reporting of individual measures: the 12-month reporting period
beginning January 1, 2008 and the 6-month reporting period beginning July 1, 2008. To qualify
to earn a 2008 Physician Quality Reporting System incentive payment through registry-based
reporting of individual measures, each eligible professional had to meet the following criteria for
satisfactory reporting:
• 	Report at least 3 individual Physician Quality Reporting System measures; and
• 	Report each measure on at least 80 % of the Medicare Part B FFS patients to whom the
measure applies.
These criteria were applicable to both 2008 reporting periods for registry-based reporting.
Consequently, there were 2 reporting options for registry-based reporting of individual measures.
No changes have been made to the criteria for registry-based reporting of individual measures
until the 2011 program year. For the 2011 Physician Quality Reporting System, measures with a
zero percent performance rate will not be counted. That is, if the recommended clinical quality
action is not performed on at least 1 patient for a particular measure or measures group reported
by the eligible professional via a registry or EHR, we will not count the measure (or measures
groups) as a measure (or measures group) reported by an eligible professional.
The 2012 Physician Quality Reporting System retained the 2011 reporting criteria for the 12-
month reporting period. The reporting options continue for registry-based reporting for the 2012
Physician Quality Reporting System of individual measures are summarized in Table 3 below.
Table 3: 2012 Criteria for Satisfactory Reporting of Individual Quality Measures through
Registries
Reporting Criteria 	Reporting Period
• 	Report at least 3 Physician Quality Reporting System
measures; and
• 	Report each measure for at least 80% of Medicare Part B
FFS patients to whom the measure applies.
• 	Measures with a zero percent performance rate will not be
counted.
January 1, 2012 –
December 31, 2012
For registry-based reporting of measures groups, there were 2 reporting periods available when
registry-based reporting of measures groups was first introduced in the Physician Quality
Reporting System for 2008: the 12-month reporting period beginning January 1, 2008 and the 6-
month reporting period beginning July 1, 2008.
For the 2008 Physician Quality Reporting System, there were 2 reporting options available for
registry-based reporting of measures groups for the 12-month reporting period. An eligible
professional could either:

28
• 	Report on at least one measures group for at least 30 consecutive patients to whom the
measures of the measures group apply; OR
• 	Report on at least one measures group for at least 80% of Medicare Part B FFS patients
to whom the measures of the measures group apply.
For the 2008 Physician Quality Reporting System, there were 2 reporting options available for
registry-based reporting of measures groups for the 6-month reporting period. An eligible
professional could either:
• 	Report on at least one measures group for at least 15 consecutive patients to whom the
measures of the measures group apply; OR
• 	Report on at least one measures group for at least 80% of Medicare Part B FFS patients
to whom the measures of the measures group apply.
There are 2 differences between the 2008 criteria for registry-based reporting of measures groups
and the 2009 criteria. The first difference is the elimination of the reporting option based on
reporting for at least 15 consecutive patients for the 6-month reporting period. The second
difference is the addition of a minimum sample size requirement for eligible professionals
reporting on at least 80% of applicable Medicare Part B FFS patients. Identical to the 2009
criteria for claims-based submission of measures groups discussed in §70.1.1 above, eligible
professionals reporting in 2009 on 80% of applicable Medicare Part B FFS patients for the 12-
month reporting period were required to have at least 30 applicable patients. Eligible
professionals reporting in 2009 on 80% of applicable Medicare Part B FFS patients for the 6-
month reporting period were required to have at least 15 applicable patients.
The 2010 criteria for registry-based reporting of measures groups are similar to the 2009 criteria
except for 2 differences. First, CMS eliminated the requirement that the 30 patients be seen
consecutively to allow an eligible professional to report on any 30 patients seen during the
reporting period. The second difference is that CMS reduced the minimum sample size
requirement for eligible professionals reporting on at least 80% of applicable Medicare Part B
FFS patients to 15 and 8 for the 12-month and 6-month reporting periods, respectively.
For the 2011 Physician Quality Reporting System, measures within a measures group with a zero
percent performance rate will not be counted. Furthermore, in registry-based reporting, in
contrast to prior program years, the minimum patient numbers or percentages must be met by
Medicare Part B FFS patients exclusively and not non-Medicare Part B FFS patients.
For reporting measures groups via registry under the 2012 Physician Quality Reporting System,
CMS retained all 3 of the 2011 reporting options for the 6 and 12-month reporting periods
described above. Therefore, the 2012 Physician Quality Reporting System criteria for
satisfactory reporting that each eligible professional must meet to qualify to earn an incentive
payment through registry-based reporting of measures groups in 2012 are summarized in Table
4 below.

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Table 4: 2012 Criteria for Satisfactory Reporting of Measures Groups through Registries
Reporting Criteria 	Reporting Period
• 	Report at least one measures group (measures groups
with a zero percent performance rate will not be
counted); and
• 	Report each measures group for at least 30 patients
Medicare Part B FFS patients to whom the measures in
the measures group apply. Measures within a
measures group with a zero percent performance rate
will not be counted.
January 1, 2012 – December
31, 2012
• 	Report at least one measures group (measures with a
zero percent performance rate will not be counted);
and
• 	Report each measures groups for at least 80 % of
Medicare Part B FFS patients to whom the measures in
the measures group applies; but
• 	Report each measures group on at least 15 Medicare
Part B FFS patients during the reporting period to
which the measures group applies.
• 	Measures within a measures group with a zero percent
performance rate will not be counted.
January 1, 2012 – December
31, 2012
• 	Report at least one measures group; and
• 	Report each measures group for at least 80 % of
Medicare Part B FFS patients to whom the measures in
the measures group applies; but
• 	Report each measures group on no less than 8
Medicare Part B FFS patients seen during the reporting
period to which the measure group applies.
• 	Measures within a measures group with a zero percent
performance rate will not be counted.
July 1, 2012 – December 31,
2012
70.1.3 – Criteria for Determination of Satisfactory Reporting of Individual
Measures for EHR-based Reporting
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Beginning with the 2010 Physician Quality Reporting System, an individual eligible professional
who chooses to report on individual Physician Quality Reporting System quality measures rather
than measures groups has the additional option of reporting on the individual Physician Quality
Reporting System quality measures via a qualified EHR product in lieu of submitting the quality
measures data on claims or via a qualified registry (see §50).
For 2010 and 2011, the criteria for determining whether an eligible professional satisfactorily
reports data on individual Physician Quality Reporting System quality measures for reporting via
an EHR was identical to the criteria for satisfactory reporting of individual Physician Quality
Reporting System quality measures via a qualified registry. However, there was only one
reporting period available for EHR-based reporting of individual measures: the 12-month

30
reporting period beginning January 1st . Consequently, there is only one reporting option for
EHR-based reporting of individual measures for the 2010 and 2011 Physician Quality Reporting
System. To qualify to earn a 2010 and 2011 Physician Quality Reporting System incentive
payment through EHR-based reporting of individual measures, each eligible professional must
meet the following criteria for satisfactory reporting:
• 	Report at least 3 individual Physician Quality Reporting System measures; and
• 	Report each measure on at least 80 % of the Medicare Part B FFS patients to whom the
measure applies.
The following changes to the EHR-based reporting option were introduced for the 2012
Physician Quality Reporting System: (1) allowing EHR-based reporting via a qualified direct
EHR product or a qualified EHR data submission vendor, and (2) adding criteria under EHR-
based reporting that are identical to the criteria for meeting the clinical quality measure objective
of achieving meaningful use under the Medicare EHR Incentive Program. The reporting options
for satisfactory reporting via the EHR-based reporting mechanism in 2012 are summarized in
Table 5 below.
Table 5: Criteria for Satisfactory Reporting of Individual Measures through EHR

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Reporting
Mechanism
Reporting Criteria 	Reporting
Period
Qualified Direct
EHR Product
• 	Report at least 3 individual Physician Quality
Reporting System EHR measures; and
• 	Report each measure on at least 80 % of the
Medicare Part B FFS patients to whom the
measure applies.
• 	Measures within a measures group with a zero
percent performance rate will not be counted.
January 1, 2012
– December 31,
2012
Qualified EHR
Data Submission
Vendor
• 	Report at least 3 individual Physician Quality
Reporting System EHR measures; and
• 	Report each measure on at least 80 % of the
Medicare Part B FFS patients to whom the
measure applies.
• 	Measures within a measures group with a zero
percent performance rate will not be counted.
January 1, 2012
– December 31,
2012
Direct EHR
Technology that
is both
“qualified” for
the Physician
Quality
Reporting
System and
Certified EHR
Technology
• 	Report on ALL three Medicare EHR Incentive
Program core measures.
• 	If the denominator for one or more of the
Medicare EHR Incentive Program core
measures is zero, report on up to three Medicare
EHR Incentive Program alternate core
measures; and
• 	Report on three (of the 38) additional measures
available for the Medicare EHR Incentive
Program.
January 1, 2012
– December 31,
2012
EHR Data
Submission
Vendor
Technology that
is both
“qualified” for
the Physician
Quality
Reporting
System and
Certified EHR
Technology
• 	Report on ALL three Medicare EHR Incentive
Program core measures.
• 	If the denominator for one or more of the
Medicare EHR Incentive Program core
measures is zero, report on up to three Medicare
EHR Incentive Program alternate core
measures; and
• 	Report on three (of the 38) additional measures
available for the Medicare EHR Incentive
Program.
January 1, 2012
– December 31,
2012
70.2 – Criteria for Determination of Satisfactory Reporting for Group
Practices and Process for Reporting by Group Practices
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In accordance with section 1848(m)(3)(C)(i) of the Act, we established, beginning with the 2010
Physician Quality Reporting System, a new process whereby group practices can qualify to earn

32
a Physician Quality Reporting System incentive based on a determination that the practice
satisfactorily reports data on Physician Quality Reporting System quality measures.
For 2010, group practice is defined under the Physician Quality Reporting System as 200 or
more individual eligible professionals.
For 2011, group practice is defined under the Physician Quality Reporting System as 2 or more
individual eligible professionals and there are two group practice reporting options (GPRO).
Group practices with 200 or more eligible professionals participate in the GPRO option named
GPRO I, whereas group practices comprised of 2-199 eligible professionals participate in the
GPRO option named GPRO II.
Effective January 1, 2012, group practice is defined under the Physician Quality Reporting
System as 25 or more individual eligible professionals. CMS eliminated the GPRO II
classification. As in prior years, realizing the size of a group practice may vary throughout the
reporting period, for purposes of determining a group practice’s reporting requirements under the
Physician Quality Reporting System, the size of the group is determined at the time the group’s
participation in one of the 2012 GPRO options is approved by CMS. However, please note that
the group practice must, at all time, have at least the minimum number of eligible professionals
required under the definition of group practice (i.e., 25 eligible professionals for 2012) in order
to participate in the GPRO.
Each group practice selected to participate in the Physician Quality Reporting System GPRO
(see §20.3 for discussion of how a group practice can qualify to participate in the Physician
Quality Reporting System GPRO) must complete a data collection web-interface that pre-
populated with an assigned sample of patients and those patients’ demographic and utilization
information. The group practice is required to populate the remaining data fields necessary for
capturing quality measure information on each of the consecutively assigned Medicare
beneficiaries with respect to services furnished during the relevant Physician Quality Reporting
System reporting period. The selected group practices are provided access to the pre-populated
web-interface no later than the first quarter of the year following the program year in which the
practice is participating in the Physician Quality Reporting System GPRO. For example, if the
group practice is participating in the 2011 Physician Quality Reporting System GPRO, the
practice would be provided access to the pre-populated web-interface no later than the first
quarter of 2012. Upon receiving access to this pre-populated data collection web-interface, the
practice must complete the remaining data elements for a specified number of patients and return
the completed web-interface to CMS.
For purposes of determining whether a group practice satisfactorily submits Physician Quality
Reporting System quality measures data for a particular program year, each selected group
practice is required to complete this data collection web-interface for a specified number of
quality measures. The quality measures are grouped into disease modules plus a series of patient
care measures. Data from the January 1 st through October 29 th NCH file for the program year
(10 months) is used by CMS to randomly assign Medicare beneficiaries to each physician group
practice TIN. Medicare beneficiaries are retrospectively assigned to the TIN based on a
determination by CMS that the group practice provided the plurality of office or other outpatient
services to the beneficiary (with a minimum of at least two visits) in the 10-month period.

33
Furthermore, part-year and managed care patients are not considered since CMS would have
incomplete claims data for these beneficiaries and group practices may not have had sufficient
time to impact the quality of their care.
For each disease module or patient care measure, depending on the group’s size, the selected
Physician Quality Reporting System GPRO practice must complete the data collection web-
interface for the first 218 (for groups comprised of 25-99 eligible professionals) or 411 (for
groups comprised of 100+eligible professionals) consecutively assigned and ranked Medicare
beneficiaries. Assigned beneficiaries will be limited to those Medicare FFS beneficiaries with
Medicare Part B for whom Medicare is the primary payer. If the pool of eligible assigned
beneficiaries is less than 218 or 411 for any module/measure, then the group practice must report
on 100% (all) of the assigned beneficiaries for that module/measure to satisfactorily participate
in the Physician Quality Reporting System GPRO.
70.2.1 – Criteria for Determination of Satisfactory Reporting for Group
Practices and Process for Reporting under the GPRO
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
For purposes of determining whether a group practice satisfactorily submits Physician Quality
Reporting System quality measures data for a particular program year, each selected group
practice is required to complete this data collection web-interface for a specified number of
quality measures. The quality measures are grouped into disease modules plus a series of patient
care measures. Data from the January 1 st through October 29 th NCH file for the program year
(10 months) is used by CMS to randomly assign Medicare beneficiaries to each physician group
practice TIN. Medicare beneficiaries are retrospectively assigned to the TIN based on a
determination by CMS that the group practice provided the plurality of office or other outpatient
services to the beneficiary (with a minimum of at least two visits) in the 10-month period.
Furthermore, part-year and managed care patients are not considered since CMS would have
incomplete claims data for these beneficiaries and group practices may not have had sufficient
time to impact the quality of their care.
In 2011, for each disease module or patient care measure, the selected Physician Quality
Reporting System GPRO I practice was required to complete the data collection web-interface
for the first 411 consecutively assigned and ranked Medicare beneficiaries. Assigned
beneficiaries will be limited to those Medicare FFS beneficiaries with Medicare Part B for whom
Medicare is the primary payer. If the pool of eligible assigned beneficiaries was less than 411 for
any module/measure, then the group practice was required to report on 100% (all) of the
assigned beneficiaries for that module/measure to satisfactorily participate in the Physician
Quality Reporting System GPRO I. The reporting mechanism, reporting period, and criteria for
satisfactory reporting under the GPRO I for 2011 are summarized in the Table 6 below.
Table 6: 2011 Physician Quality Reporting System Process for Physician Group Practices
to Participate as Group Practices and Criteria for Satisfactory Reporting of Data on
Quality Measures by Group Practices for GPRO I

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Reporting
Mechanism
Reporting Criteria 	Reporting
Period
A pre-
populated
data
collection
web-
interface
provided by
CMS
• 	Report on all measures included in the data collection
web-interface (26 measures); and
• 	Complete the web-interface for the first 411 consecutively
ranked and assigned beneficiaries in the order in which
they appear in the group’s sample for each disease module
or patient care measure. If the pool of eligible assigned
beneficiaries is less than 411, then report on 100% of
assigned beneficiaries.
January 1,
2011–
December
31, 2011
In addition, for 2011, GPRO II groups were required to report on a specified number of
individual measures and measures groups depending on the group practice's size. For individual
measures reporting, GPRO II groups were required to report on a specified percentage of
patients. To satisfactorily report measures groups for the 2011 Physician Quality Reporting
System GPRO II, the group practice need only report on the minimum number of patients
specified in Table 9 for their group size. In addition, since we did not have the ability to
determine whether the registries can ensure that only unique patients are counted, GPRO II
groups were required to report the 2011 Physician Quality Reporting System data via claims
unless the only measures groups that apply to the practice are one of the four registry-only
measures groups. Group practices that must report on one of the four registry-only measures
groups in order to meet the criteria for satisfactory reporting were able to use the registry-
reporting mechanism to submit all of their 2011 Physician Quality Reporting System data via the
registry reporting mechanism. The reporting mechanism, reporting period, and criteria for
satisfactory reporting under the GPRO II for 2011 are summarized in the Table 7 below.

35
Table 7: 2011 Physician Quality Reporting System Process for Physician Group Practices
to Participate as Group Practices and Criteria for Satisfactory Reporting of Data on
Quality Measures by Group Practices for GPRO II
Group size
(number of
eligible
professionals)
Number of
measures
groups
required to
be reported
Minimum
number of
Medicare
Part B
patients in
denominator
for
satisfactory
reporting of
measures
groups
Number of
individual
measures
required to
be reported
Percent of
Medicare
Part B
patients in
denominator
for
satisfactory
reporting of
individual
measures via
claims (%)
Percent of
Medicare
Part B
patients in
denominator
for
satisfactory
reporting of
individual
measures via
registries
(%)
2-10 	1 	35 	3 	50 	80
11-25 	1 	50 	3 	50 	80
26-50 	2 	50 	4 	50 	80
51-100 	3 	60 	5 	50 	80
101-199 	4 	100 	6 	50 	80
In 2012, the GPRO II reporting option was eliminated, leaving a single GPRO reporting option.
However, CMS finalized two different satisfactory reporting criteria under the GPRO for groups
comprised of 25-99 eligible professionals and groups comprised of 100+ eligible professionals.
With respect to the criteria for satisfactory reporting for groups comprised of 25-99 eligible
professionals, for each disease module or patient care measure, the selected Physician Quality
Reporting System GPRO practice must complete the data collection web-interface for the first
218 consecutively assigned and ranked Medicare beneficiaries. Assigned beneficiaries will be
limited to those Medicare FFS beneficiaries with Medicare Part B for whom Medicare is the
primary payer. If the pool of eligible assigned beneficiaries was less than 218 for any
module/measure, then the group practice is required to report on 100% (all) of the assigned
beneficiaries for that module/measure to satisfactorily participate in the Physician Quality
Reporting System GPRO.
With respect to the criteria for satisfactory reporting for groups comprised of 100+ eligible
professionals, for each disease module or patient care measure, the selected Physician Quality
Reporting System GPRO practice must complete the data collection web-interface for the first
411 consecutively assigned and ranked Medicare beneficiaries. Assigned beneficiaries will be
limited to those Medicare FFS beneficiaries with Medicare Part B for whom Medicare is the
primary payer. If the pool of eligible assigned beneficiaries was less than 411 for any
module/measure, then the group practice was required to report on 100% (all) of the assigned
beneficiaries for that module/measure to satisfactorily participate in the Physician Quality
Reporting System GPRO.

36
The reporting mechanism, reporting period, and criteria for satisfactory reporting under the
GPRO for 2012 are summarized in the Table 8 below.
Table 8: 2012 Criteria for Satisfactory Reporting of Data on Quality Measures by Group
Practices for theGPRO
Group Size 	Reporting
Mechanism
Reporting Criteria 	Reporting
Period
25-99
eligible
professionals
A
submission
web
interface
provided by
CMS
• 	Report on all measures included in the
web-interface (29 measures); and
• 	Populate the data field for the first 218
consecutively ranked and assigned
beneficiaries in the order in which they
appear in the group’s sample (with an
over-sampler of 327) for each disease
module or patient care measure. If the
pool of eligible assigned beneficiaries is
less than 218, then report on 100% of
assigned beneficiaries.
January 1,
2012–
December
31, 2012
100+
eligible
professionals
A
submission
web
interface
provided by
CMS
• 	Report on all measures included in the
web-interface (29 measures); and
• 	Populate the date fields for the first 411
consecutively ranked and assigned
beneficiaries in the order in which they
appear in the group’s sample (with an
over-sample of 616) for each disease
module or patient care measure. If the
pool of eligible assigned beneficiaries is
less than 411, then report on 100% of
assigned beneficiaries.
January 1,
2012–
December
31, 2012
80 – Limitations on Review
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
Section 1848(m)(5)(E) of the Act, except for the informal review process noted below, there is
no administrative or judicial review or otherwise of the determination of: (1) the determination of
quality measures applicable to services furnished by eligible professionals, (2) the determination
of satisfactory reporting, or (3) the determination of any incentive payment.
However, section 1848(m)(5)(I) of the Act, as added by the Affordable Care Act, requires the
establishment of an informal review process by January 1, 2011. As such, beginning with the
2011 Physician Quality Reporting System, eligible professionals may seek an informal review of
the determination that an eligible professional or group practice did not satisfactorily submit data
on quality measures under the Physician Quality Reporting System. To request an informal
review, an eligible professional or group practice must submit a written request to CMS within

37
90 days of the release of the applicable year’s feedback reports. The request must state the
eligible professional’s or group practice’s reasons for requesting an informal review which may
include information to assist in the review. CMS will provide a final, written response to the
request within 60 days of the receipt of the original request. With respect to an informal review
request received in 2012 based on 2011 data, CMS will provide a final, written response to the
request within 60 days of the receipt of the original request. With respect to an informal review
request received in 2013 based on 2012 data and subsequent years, CMS will provide a final,
written response to the request within 90 days of the receipt of the original request. All decisions
are final and are not subject to further review.
90 – Confidential Feedback Reports
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
In accordance with section 1848(m)(5)(H) of the Act, CMS provides confidential annual
feedback reports on Physician Quality Reporting System reporting to participating eligible
professionals at or near the time that the lump sum incentive payments for a particular payment
year are made. Feedback reports for the 2009 Physician Quality Reporting System, for example,
would be provided in 2010.
In addition to confidential annual feedback reports, beginning 2012, CMS will provide
confidential interim feedback reports on Physician Quality Reporting System reporting.
Access to confidential feedback reports may require eligible professionals to complete an
identity-verification process. However, receipt of a report is not required to participate in the
Physician Quality Reporting System or to receive an incentive payment.
Feedback reports are available for every TIN under which at least one eligible professional
(identified by his or her National Provider Identifier, or NPI) submitting Medicare Part B FFS
claims reported at least one valid Physician Quality Reporting System measure a minimum of
once during the reporting period. Thus, to receive a feedback report the eligible professional
must have had at least one valid Physician Quality Reporting System submission. A valid
submission is defined as receipt by CMS of the correct numerator, denominator codes, age and
gender (where applicable) as listed in the applicable Physician Quality Reporting System quality
measure specifications manual. The Physician Quality Reporting System quality measure
specifications are subject to change for each program year. The Physician Quality Reporting
System quality measure specifications manual for the current or an upcoming program year is
posted on the Measures Codes page at http://www.cms.gov/PQRS. 	Physician Quality Reporting
System measure specifications for prior program years are archived on the appropriate Physician
Quality Reporting System Program page of the CMS Physician Quality Reporting System
website at http://www.cms.gov/PQRS.
In addition, section 1848(m)(5)(G) of the Act requires CMS to post on the CMS website, in an
easily understandable format, a list of the names of the eligible professionals who satisfactorily
submitted data on quality measures under Physician Quality Reporting System. Therefore,
beginning with the 2009 Physician Quality Reporting System, the names of eligible professionals
and group practices who satisfactorily submit data on quality measures for the Physician Quality
Reporting System will be posted on http://www.medicare.gov. The names of eligible

38
professionals (and group practices) who satisfactorily submit data on quality measures for a
particular year are publicly posted after the lump sum incentive payments for that program year
are made in the following year.
100 – Direct Mailings
(Rev. 10, Issued: 07-27-12, Effective: 10-29-12, Implementation: 10-29-12)
At the request of CMS, contractors shall print and distribute hardcopy mailings to all or a subset
of their active providers related to the Physician Quality Reporting System. Mailings shall be
sent to the best address to reach the provider, not the billing agency used by the provider. As
such, contractors should consider using the correspondence address in PECOS if it is available.

39
Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date 	CR#
R82QRI 	03/22/2019 	Update to Publication 100-22 to Provide
Language-Only Changes for the New Medicare
Card Project
04/22/2019 	11166
R31QRI 	08/29/2014 	Language-Only Changes for Updating ICD-10
and ASC X12 Language in Pub 100-22, Chapters
1 and 2
09/30/2014 	8787
R10QRI 	07/27/2012 	Physician Quality Reporting System and
Electronic Prescribing (eRx) Incentive Program
10/29/2012 	7879
R1QRI 	06/11/2010 	Physician Quality Reporting Initiative (PQRI)
and E-Prescribing (eRx) Medicare Quality
Reporting Incentive Programs Manual
09/13/2010 	6935